Faculty Bibliography

We present the unique opportunity to correlate videostroboscopic findings with histologic examination. An immunocompromised patient with hoarseness because of ulcerative lesions of both vocal folds of uncertain cause died within a few weeks of initial presentation, and the larynx was donated for postmortem examination. Relevant history, as well as endoscopic and histopathologic findings, is presented

OBJECTIVE: Dehydration challenges can increase the chemical composition of surface fluid overlying vocal fold epithelia (hypertonic surface fluid). The vocal fold epithelium is posited to act as a barrier, shielding the lamina propria from perturbations in the airway lumen. However, the effects of hypertonic surface fluid on the barrier functions of vocal fold epithelia have not been quantified. We, therefore, sought to investigate whether hypertonic surface fluid compromises epithelial barrier function. We examined the effects of hypertonic surface fluid on vocal fold epithelial resistance, paracellular pathway morphology, and tight junction protein integrity. STUDY DESIGN: Ex vivo, between group design. SETTING: Laboratory. METHODS: Porcine vocal folds (n = 24) were exposed to hypertonic or isotonic challenge and examined by electrophysiology, transmission electron microscopy, and Western blot analyses. RESULTS: Hypertonic, but not isotonic, challenge significantly reduced transepithelial resistance. This decrease in resistance was observed immediately after the challenge and was consistent with the appearance of dilated paracellular pathway morphology. However, hypertonic challenge did not alter protein levels of occludin, zona occludens-1, E-cadherin, or beta-catenin. CONCLUSION: Hypertonic surface fluid alters epithelial barrier function in the vocal folds. Specifically, exposure to hypertonic challenges increases epithelial permeability. Given the important role of the vocal fold epithelium in shielding the underlying mucosa from inhaled pathogens and pollutants, our data provide the impetus for future studies on pharmacological treatments aimed at restoring the hydration level and chemical composition of vocal fold surface fluid

OBJECTIVES/HYPOTHESIS:: Medulloblastoma is the most common pediatric malignant tumor of the central nervous system in children. Treatment includes surgical excision, external beam radiation, and multiagent chemotherapy. Otologic sequelae are common and may result from radiation and/or chemotherapy. Profound sensorineural hearing loss (SNHL) is a known complication of neuro-oncologic treatment and may render these patients eligible for cochlear implantation (CI). Issues of CI in this population, including diagnosis, treatment of preoperative middle ear disease, operative and postoperative course, performance data, and long-term tumor surveillance are highlighted and reviewed. STUDY DESIGN:: Retrospective chart review. METHODS:: Three patients treated for pediatric medulloblastoma with surgical resection, postoperative hyperfractioned craniospinal radiotherapy, and multiagent adjuvant chemotherapy who underwent cochlear implantation were identified. Details of neuro-oncologic treatment and associated otologic complications are presented and analyzed. Primary outcome assessment includes treatment of middle ear pathology, perioperative cochlear implant course, and postimplantation performance data. RESULTS:: Each patient required surgical treatment of chronic ear disease 4 to 16 years after chemoradiation. All progressed to profound SNHL and were implanted 8 to 17 years post-neuro-oncologic treatment. There were no intraoperative complications, and full insertion of the cochlear implant electrode array was achieved in each patient. One patient developed postoperative wound dehiscence requiring operative closure. Postimplantation performance data support significant benefit in all patients. CONCLUSIONS:: Patients treated for pediatric medulloblastoma develop otologic sequelae, including profound SNHL, and may require cochlear implantation. Successful management of middle ear and mastoid pathology involves consideration of potential future cochlear implantation. Postoperative performance data supports cochlear implantation in this population. Laryngoscope, 2009

OBJECTIVES/HYPOTHESIS/OBJECTIVE:The objective of this study was to review clinical outcomes of minimally invasive endoscopic resection (MIER) for anterior skull base (ASB) neoplasms. STUDY DESIGN/METHODS:Retrospective data review. METHODS:Data analysis was performed on all patients undergoing MIER from October 2000 to December 2008. RESULTS:Thirty-one patients with mean age of 58 years underwent MIER. Malignant and benign tumors were managed in 25 (80.6%) and six (19.4%) cases, respectively. Most common histopathologies were squamous cell carcinoma (six), esthesioneuroblastoma (five), mucosal melanoma (five), and sinonasal undifferentiated carcinoma (four). American Joint Committee on Cancer tumor staging was T3N0M0 and T4N0M0 in 14 (56%) and 11 (44%) of the malignant cases, respectively. Surgical resection with curative intent was performed in 28 cases (90.3%). Multilayered skull base reconstruction was performed in most patients; lumbar drains were used in eight cases (25.8%). Twenty-one patients (67.7%) were disease free, five patients (16.1%) were dead from disease, three patients (9.7%) were alive with disease, and two patients (6.5%) died from unrelated causes at mean follow-up of 31.7 months. CONCLUSIONS:This study validated technical feasibility of MIER for diversity of benign and malignant ASB histopathology. Majority of patients were able to avoid adjunct craniotomy, whereas lumbar drainage was utilized in selective cases. This surgical strategy resulted in low complication rate and acceptable disease-free survival in patients with advanced T3 and T4 malignant lesions. Future studies should focus on multicenter trials to facilitate more robust survival analysis and comparison to open surgical approaches.

OBJECTIVE: To quantify tissue tearing force at various anchoring points on the face. METHODS: This is a prospective anatomic study using 4 fresh cadavers of persons aged 60 to 70 years at the time of death, for a total of 8 sides. Standardized 1-cm distances were measured at the various anchor points, and a single 0 Prolene suture loop was tied at each standardized anchoring point. Steady force was applied perpendicular to the plane of the face with a digital hanging scale. The scale was pulled until the suture ruptured the tissue at the anchoring point. The values at which the tissue ruptured were recorded, averaged, and compared. RESULTS: The average tissue force was 7.01 kg for the root of the zygoma vs 3.44 kg for the temporalis fascia (P < .05). The average tissue force was 5.50 kg for infralobular tissue vs 4.09 kg for tissue of the superficial musculoaponeurotic system located 1 cm anterior to the infralobular tissue (P < .05). The force for the fascia of the sternocleidomastoid was 3.89 kg vs 5.57 kg for the mastoid fascia (P < .05). There was a statistically significant difference between vertical bites of the temporalis fascia at 1.90 kg vs horizontal bites of the temporalis at 5.01 kg (P < .05). CONCLUSION: The tissue tearing force varies by location on the face as well as suture orientation

OBJECTIVES: To present a rare case of facial nerve paraganglioma and novel use of a processed allograft for facial nerve reconstruction. STUDY DESIGN: Case report and review of the literature. METHODS: A 34 year old female presented with progressive onset right sided facial palsy for 5 months. CT and MRI demonstrated an irregular mass in the right facial nerve canal from the intratympanic segment to the stylomastoid foramen. RESULTS: Following transmastoid resection, the defect was repaired using processed allograft. Pathologic analysis was consistent with a paraganglioma. Facial nerve paraganglioma is a rare entity that has been reported only 10 times in the literature. CONCLUSIONS: Traditional methods of facial nerve reconstruction, including autologous and cadaveric grafting, can lead to significant patient morbidity. Autologous nerve grafts are the 'gold standard' for superior regenerative capability, but are limited by the length and potential neuroma formation at the donor site. Allogenic grafts from donors or cadavers have shown some efficacy, but can require immunosuppression. The Avance nerve graft is a cadaveric graft, processed and decellularized to maintain an extracellular matrix with laminin and intact endoneural tubes, thus providing support for the growing axon without generating an immune response. Initial studies of the Avance graft in animals and humans have examined repair of peripheral nerves, but this is the first reported case of human facial nerve reconstruction